Scenario 1—A: The nurse practitioner may act as the supervising physician if it’s within the scope of practice for the NP and should be coded as follows:
CPT: 96413, 96415, J1745 x 30, J1200 x 1
Diagnosis ICD:10: M05.79
Scenario 2—A: To qualify as an incident-to service, the PA can provide the infusion service if it is within the scope of their practice and a supervising physician is in the office suite. It should be coded as follows:
CPT: 96413, 96415 x 2, J1745 x 60, J1200 x 1
Diagnosis ICD:10: M05.79
Billing Rationale
Medicare Billing Option #1: Direct Billing
NPs, clinical nurse specialists and PAs may apply for individual provider numbers for direct billing purposes. All covered services rendered may be billed using the nonphysician practitioner’s (NPP’s) direct provider number.
Medicare Billing Option #2: Incident-to Billing
Rather than bill directly for services provided as outlined in Option #1, an NPP may provide services incident-to a physician’s professional services and bill accordingly for those services.
Even though an NPP may be licensed under state law to perform a specific medical procedure and may be able to perform that medical procedure without physician supervision and have the service separately covered and paid by Medicare (as defined in Option #1), all criteria must be met for those services to be covered as incident-to in Option #2.
As of January 2020, the Centers for Medicare & Medicaid Services (CMS) has redefined supervision of nonphysician providers: NPs can continue to work in collaboration with the physician or work independently, but CMS leaves it up to individual states to decide the level of supervision for PAs.
The current policy requires general physician supervision for PA services; however, CMS’ revisions provide that the statutory physician supervision requirement for PA services is met when a PA furnishes their services in accordance with state law and scope of practice rules for PAs in the state in which the services are furnished. In the absence of state law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documenting at the practice level the PA’s scope of practice and the working relationship the PA has with the supervising physician(s) when furnishing professional services.
This does not change the incident-to guidelines as they relate to payment. If there is direct supervision of a physician in the suite for an established patient with an established diagnosis, then the encounter is reimbursable at 100% of the Part B Physician Schedule. If all the criteria are not met for incident-to billing, then all other scenarios will be reimbursed at 85%. If no physician is present, this would require the NP or PA to have their own National Provider Identifier (NPI) number to bill Medicare for the encounter.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at mtillman@rheumatology.org or call 404-633-3777 x820.